In a recent article, Malcolm Gladwell dissected and diagnosed American health care.
Throughout our interview, he tackled controversial topics from the Affordable Care Act and medical malpractice to the contrasting Canadian health care system and much more. I expected him to dive deep below the surface and provide new and intriguing perspectives. He didn’t disappoint.
But it was his closing comment that caught me off guard. When I asked Gladwell what topics he thought I should cover in future Forbes blogs, he said, “Help people understand what it is really like to be a physician.”
I did not see that coming. I figured he’d request an expose on Big Pharma, an in-depth examination of various medical conditions or a portrait of preventive care. But explaining what it’s really like to be doctor is a much more personal request and, as it turned out, much more challenging.
The duality of being a doctor
Most physicians go into medicine with a mission-driven spirit, committed to helping people. They are grateful for the opportunity to care for others, proud of their ability to diagnosis and treat, and inspired by the trust their patients put in them.
But those experiences contrast vividly with the economic side of being a physician. Each day, mundane financial tasks distance doctors from the reasons they chose medicine as a career in the first place.
That’s the duality of being a doctor. There’s the fulfilling personal side and the frustrating impersonal side. The personal side reminds doctors why they love practicing medicine. The impersonal side poses a significant threat to the future of medicine. Let me begin by explaining the personal side.
Awe and terror: The clinic side of practicing medicine
For academically outstanding students with a desire to improve the lives of others, becoming a physician is a great career choice. They work hard in their training to master both the science and art of modern clinical practice.
This hardworking and altruistic spirit is necessary for aspiring doctors to endure the physically, emotionally and financially taxing aspects of medical school and residency training. And that’s where future physicians experience both awe and humility as they navigate the complex journey of becoming a doctor.
They spend their days exploring the mysteries of the human body. They learn to decipher medical secrets by looking into the eye, listening to the heart and palpating the abdominal organs. They gain the competence and confidence needed to cut open a body with a scalpel, insert scopes into the different orifices and cavities, and remove damaged tissue to eradicate disease and restore health.
Out of context, these practices would constitute assault and battery. In medicine, these activities are essential. Being entrusted to perform them is a privilege afforded only to those who earn the title of “doctor.” It is an awesome responsibility.
Physicians are permitted and often required to ask deeply personal questions. Patients answer willingly. The intense and intimate nature of the doctor-patient relationship represents a unique bond, a trust forged in just a matter of minutes during a standard clinical encounter.
The majesty of the human body, the importance of health, and the personal fulfillment that comes from healing define the physician’s world and the clinical practice of medicine.
But along with the awe and pride comes an underlying terror.
As physicians treat patients, they are afraid of making a mistake or harming someone. Physicians worry about missing a life-threatening diagnosis, unintentionally spreading infection or committing a technical error. This fear isn’t just the self-protective paranoia of being sued for malpractice. It stems from a profound anxiety of violating the deeply embedded, core principle of the profession: Primum non nocere or “first, do no harm.”
Most nights, physicians go to sleep fulfilled and grateful for the honor of becoming a part of their patients’ lives. And overall, the opportunity to make a difference is fulfilling and satisfying.
But when something goes wrong, the agony runs deep. There are sleepless nights filled with tossing, turning and painful reflection.
Claims and pains: The clerical side of practicing medicine
As fulfilling as patient care is, most doctors (particularly those in individual and small practices) lament the other side of the job: the business of health care.
As much as half of each day can be consumed with clerical and administrative tasks: completing insurance claims forms, navigating complex coding requirements, and negotiating with insurance companies over prior approvals and payment rates. And this affects not only physicians, but also their patients – further complicating medical practice and increasing the level of frustration.
In my conversation with Gladwell, he spoke about a doctor’s office he’d recently visited. He described interacting with four support staff: three doing paperwork and only one assisting the physician with medical care.
“That’s insane,” he said. “The only other industry in America that has a higher ratio of back-office to front-office is financial services, which also is a massively crazy business. It’s just wrong. It’s a misuse of resources.”
He also expressed concerns about the economics of medical practice and the consequences for physicians:
“I don’t understand, given the constraints physicians have in doing their job and the paperwork demanded of them, why people want to be physicians. I think we’ve made it very, very difficult for them to perform their job. I think that’s a shame. My principal concern is the amount of time and attention spent worrying about the business side. You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.”
It’s this side of medical practice that wears down even the best physicians.
Yet it’s the reality for many American doctors, particularly those in small offices, who are reimbursed on a fee-for-service basis. Filling out claims forms and managing thousands of billing codes are frustrating and exhausting tasks. No wonder multiple surveys over the past two decades show a progressive decline in doctor satisfaction among those in community practices.
It’s not the long hours or the demands of patient care that have eroded their satisfaction. It’s the insurance side of health care.
And in 2012, a study found that 9 out of 10 physicians across the country areunwilling to recommend the profession to others.
Where does that leave the future of medical practice?
The life of a practicing physician can be incredibly rewarding. Making challenging diagnoses, helping patients deal with and overcome devastating illness and comforting families after the loss of a loved one — these are powerful emotional experiences. Across history, they have provided physicians with a profound sense of fulfillment.
But the insurance system can erode the professional and personal satisfaction of even the most dedicated physicians. That’s why it has to change.
The solution is not a government-run program with the inevitable red tape and endless regulations. This will only make matters worse. Instead, improving the situation will require a systematic shift — one that moves away from doctors being paid for volume to one that rewards value in a predictable, prepaid way.
It will require helping doctors transition their practices from individual and small office settings to working in integrated, physician-led medical groups. The organizations that have done this have seen higher quality outcomes and increased physician satisfaction.
Malcolm Gladwell: A much-needed catalyst for change
I left Gladwell’s New York residence hoping that he would apply his powerful and paradigm-shifting insights to the health care world. I’m optimistic he can help create a new language and lens through which our nation can discuss the health care challenges we face.
If he decides to write a book about American health care, I predict the opening chapters of his book will contrast the past five millennia of clinical practice (ones filled with dedication, commitment and fulfillment) against the harsh reality and financial challenges the profession faces today. And maybe, just maybe, his words will serve as a catalyst for system-wide change. Let’s hope so.
Robert Pearl is a physician and CEO, The Permanente Medical Group. This article originally appeared on Forbes.com.
